| (a) A limited services rural hospital (LSRH) shall
adopt, implement, and enforce administrative policies and procedures
to ensure the orderly and efficient management of the LSRH. An LSRH's
administrative policies and procedures shall include the following
administrative responsibilities:
(1) enforcing policies delegated by the governing body;
(2) employing qualified management personnel;
(3) long-range and short-range planning for the LSRH's
needs, as determined by the governing body;
(4) using methods of communicating and reporting, designed
to ensure the orderly flow of information within the LSRH;
(5) controlling the purchase, maintenance, and distribution
of the LSRH's equipment, materials, and facilities;
(6) establishing lines of authority, accountability,
and personnel supervision;
(7) establishing controls relating to the custody of
the LSRH's official documents; and
(8) maintaining the confidentiality, security, and
physical safety of data on patients and staff.
(b) The LSRH shall adopt, implement, and enforce personnel
policies to facilitate the LSRH attaining its mission, goals, and
objectives. The LSRH's personnel policies shall:
(1) define and delineate functional responsibilities
and authority;
(2) require LSRH personnel to have qualifications commensurate
with their job responsibilities and authority, including appropriate
licensure or certification;
(3) require documented periodic appraisal of each person's
job performance;
(4) specify employment responsibilities and privileges;
(5) be made known to employees at the time of employment;
and
(6) provide and document adequate orientation and training
to familiarize all personnel with the LSRH's policies, procedures,
equipment, and facilities.
(c) An LSRH shall include all employee categories in
personnel policies and shall develop appropriate job descriptions
for each position.
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